Primary care clinics with a higher proportion of minority patients appear to have more adverse physician workplace conditions and challenging organizational characteristics, according to a report in the February 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
"Minority Americans have poorer health outcomes from chronic conditions such as cancer, asthma, heart disease and diabetes mellitus," the authors write as background information in the article. "Some of these poorer outcomes are attributable to disparities in health care resulting from a myriad of access, patient and physician factors."
Anita B. Varkey, M.D., of Loyola University Medical Center, Maywood, Ill., and colleagues analyzed data collected from surveys of 96 clinic managers, 388 primary care physicians and 1,701 adult patients with chronic diseases completed between 2001 and 2005. They compared data from 27 of the 96 clinics whose patient base was composed of at least 30 percent minority patients to those from the other 69 clinics. The 27 clinics serving a high proportion of minorities accounted for 162 of 388 physicians (41.8 percent) and 780 of 1,701 patients (45.9 percent) who participated.
"Physicians from 27 clinics with at least 30 percent minority patients reported less access to medical supplies and to referral specialists than physicians from the other clinics," the authors write. "These 27 clinics had poorer access to pharmacy services, fewer patient examination rooms per physician and limited written educational materials for patients with hypertension and congestive heart failure."
Physicians at these clinics were four times more likely to report having a chaotic work environment and half as likely to report having high job satisfaction. In addition, these physicians were more likely to report that their patients speak little to no English (27.1 percent vs. 3.4 percent), have chronic pain (24.1 percent vs. 12.9 percent), and are medically (53.1 percent vs. 39.9 percent) and psychosocially (44.9 percent vs. 28.2 percent) complex. The patients were more frequently depressed (22.8 percent vs. 12.1 percent), are more often covered by Medicaid (30.2 percent vs. 11.4 percent) and report lower health literacy (3.7 vs. 4.4, on a scale where one is lowest and five is highest).
"This study provides evidence of resource and workplace organizational disparities between clinics that serve large numbers of minority patients and clinics that do not," the authors write. "These deficiencies may contribute to physician stress and time pressure, thereby complicating interactions with disproportionately higher percentages of medically and psychosocially complex patients. The combination of time pressure, insufficient resources and complex patients likely constitutes a 'perfect storm' that contributes to the challenges that physicians face in providing quality care to large proportions of minority patients."
"National strategies to examine and intervene in health care disparities should consider the work environment as a potential determinant of disparities and as a target for interventions to reduce physician burnout, increase work control and reduce clinic chaos," they conclude. These interventions may include better reimbursement for primary care and more widely available health insurance.
The design and conduct of the study were supported by a grant from the Agency for Healthcare Research and Quality. Interpretation of the data and preparation of the manuscript were funded by a grant from the Robert Wood Johnson Foundation. Co-author Dr. Ibrahim is a Robert Wood Johnson Foundation Harold Amos Faculty Development Scholar.
- Anita B. Varkey; Linda Baier Manwell; Eric S. Williams; Said A. Ibrahim; Roger L. Brown; James A. Bobula; Barbara A. Horner-Ibler; Mark D. Schwartz; Thomas R. Konrad; Jacqueline C. Wiltshire; Mark Linzer; for the MEMO Investigators. Separate and Unequal: Clinics Where Minority and Nonminority Patients Receive Primary Care. Arch Intern Med., 2009; 169 (3): 243-250
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